Provider Demographics
NPI:1184963845
Name:SEDRO WOOLLEY FAMILY DENTAL CENTER, P.S.
Entity type:Organization
Organization Name:SEDRO WOOLLEY FAMILY DENTAL CENTER, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HANSROLF
Authorized Official - Middle Name:H
Authorized Official - Last Name:GRUENER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-855-0351
Mailing Address - Street 1:830 METCALF ST
Mailing Address - Street 2:
Mailing Address - City:SEDRO WOOLLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98284-1423
Mailing Address - Country:US
Mailing Address - Phone:360-855-0351
Mailing Address - Fax:360-855-9357
Practice Address - Street 1:830 METCALF ST
Practice Address - Street 2:
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284-1423
Practice Address - Country:US
Practice Address - Phone:360-855-0351
Practice Address - Fax:360-855-9357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603264506261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental